NBME questions

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Posted by Usmleguy from IP 69.253.73.95 on July 12, 2006 at 13:45:37:

33. A 14-year-old boy is brought to the physician by his parents because of a 2-year history of increasing academic problems. His parents say that he has always been hyperactive and distractible, but now his academic performance has deteriorated to the point that he is failing ninth grade. His teachers say that his hyperactivity is disrupting the classroom. He weighs 54 kg (120 lb) and is 152 cm (60 in) tall. Sexual development is Tanner stage 5; examination shows macro-orchidism, which was not shown on previous examinations. He has a high forehead and long, protruding ears. He exhibits poor eye contact during the examination. Psychoeducational testing shows an IQ of 70. Which of the following is the most likely diagnosis?

A ) Attention-deficit/hyperactivity disorder

B ) Autistic disorder

C ) Down syndrome

D ) Fetal alcohol syndrome

E ) Fragile X syndrome

F ) Lesch-Nyhan syndrome

G ) Pervasive developmental disorder, not otherwise specified

H ) Prader-Willi syndrome

I ) Rett's disorder

J ) Seminiferous tubule dysgenesis (Klinefelter's syndrome)


34. A 3-year-old girl is brought to the physician after her mother noted blood on her underpants. Examination shows genital condylomata acuminata in the perineal, peri-introital, labial, and anal areas. Some of the pedunculated condylomata appear to have caused the bleeding. She has no visible intravaginal condylomata or vaginal or anal tears. Her mother has a palmar wart on her hand but no history of condylomata acuminata. Her mother has a boyfriend who does not live with them and who has never been left alone with the girl. They live with the mother's 27-year-old brother who only baby-sits the children when they are asleep. Which of the following is the most appropriate next step in management?

A ) Psychiatric assessment of the mother

B ) DNA typing of the mother's palmar wart for papillomavirus

C ) Treatment of the mother's palmar wart

D ) Vaginal, anal, and throat cultures for Chlamydia trachomatis and Neisseria gonorrhoeae in the child

E ) Laser therapy of the condylomata acuminata in the child


select the most likely cause of urinary incontinence.
A previously healthy 44-year-old woman, gravida 4, para 4, comes to the physician because of a 9-month history of progressive loss of small amounts of urine while running; she now has to wear an absorbent pad. Examination shows a second-degree cystourethrocele.


A ) Detrusor instability

B ) Interstitial cystitis

C ) Overflow incontinence

D ) Stress incontinence

E ) Urethra diverticulum

F ) Urinary fistula


23. A 28-year-old woman is hospitalized after taking a massive overdose of acetaminophen tablets in a suicide attempt. She has type 1 diabetes mellitus and major depressive disorder refractory to tricyclic antidepressant therapy. Despite appropriate therapy, she develops rapidly progressive hepatic failure and becomes progressively encephalopathic. On the 6th day of hospitalization, she is comatose. A CT scan of the brain shows mild diffuse swelling. An appropriately crossmatched, size-appropriate donor liver is available. Which of the following is the most appropriate course of action regarding transplantation?

A ) Do not proceed with the transplantation because diabetes mellitus is a contraindication

B ) Do not proceed with the transplantation because hepatic function is likely to return over the next week

C ) Do not proceed with the transplantation because major depressive disorder places the patient at risk for another suicide attempt

D ) Do not proceed with the transplantation because the onset of encephalopathy and CT findings suggest bacterial meningitis

E ) Proceed with the transplantation

24. An 87-year-old nursing home resident with dementia, Alzheimer's type, is admitted to the hospital because of progressive lethargy and decreased appetite for 3 days. She had a flu-like illness followed by a deep cough 1 week ago. Over the past 10 months, she has been hospitalized once for bacterial pneumonia. She is responsive only to painful stimuli. Her temperature is 38.6 C (101.5 F), blood pressure is 110/60 mm Hg, pulse is 123/min and regular, and respirations are 28/min. Examination shows dry mucous membranes. There is no adenopathy. Crackles are heard in the right lung base. An x-ray film of the chest shows an infiltrate at the right lung base. The remainder of the examination shows no abnormalities. Which of the following is the most likely predisposing factor for this patient's pneumonia?

A ) Decreased airway elasticity

B ) Decreased baroreflex

C ) Decreased gag reflex

D ) Decreased thyroid function

E ) Diastolic cardiac dysfunction

F ) Impaired cardiac response to exercise

G ) Impaired T-lymphocyte function

H ) Impaired thirst

I ) Increased lung compliance

J ) Renal salt wasting


29. A 77-year-old woman comes to the physician because of a 2-day history of cramping abdominal pain and distention accompanied by nausea and vomiting. She is otherwise healthy and has no history of abdominal operations. Her temperature is 37.4 C (99.4 F), blood pressure is 110/86 mm Hg, pulse is 112/min, and respirations are 24/min. Cardiopulmonary examination shows no abnormalities. Examination of the abdomen shows distention and mild diffuse tenderness; bowel sounds are high-pitched. An x-ray film of the abdomen shows air-fluid levels throughout the small bowel and air in the liver; there is no gas in the colon or free air. Which of the following is the most likely diagnosis?

A ) Adhesive small-bowel obstruction

B ) Cecal cancer

C ) Gallstone ileus

D ) Intussusception

E ) Mesenteric infarction

F ) Ruptured appendicitis

G ) Small bowel lymphoma


41. A 72-year-old man comes to the physician because of a 7-month history of leg weakness and dry eyes and mouth. He also has had a 10.4-kg (23-lb) weight loss over the past 4 months despite no change in appetite. He has smoked one and a half packs of cigarettes daily for 50 years. He drinks 4 oz of alcohol daily. He has peptic ulcer disease and emphysema. Medications include cimetidine, theophylline, and low-dose prednisone. Examination shows mild ptosis. He has a barrel-shaped chest. Breath sounds are distant. There is moderate weakness of the proximal muscles of the lower extremities. Reflexes are absent. He has difficulty rising from a chair. Sensory examination shows no abnormalities. An x-ray film shows a hyperinflated chest and a 3 x 4-cm mass in the right hilum. His neurologic findings are most likely due to a lesion involving which of the following?

A ) Muscle membrane

B ) Parasympathetic nervous system

C ) Peripheral nerve

D ) Presynaptic neuromuscular junction

E ) Sympathetic nervous system


. A 77-year-old woman is brought to the physician by her son for a routine health maintenance examination. She says that she feels well. Her son reports that 1 month ago, she got lost while driving home from the local supermarket. Two weeks ago, she forgot to turn off the stove after cooking dinner. She has been wearing bilateral hearing aids since audiometry 2 years ago showed bilateral high-frequency hearing loss. Her visual acuity corrected with glasses is 20/25 in both eyes. Neurologic examination shows mild fine tremors of the hands when the arms are outstretched; the tremor is not present at rest. Muscle strength is 5/5 in all extremities. Deep tendon reflexes are decreased at the ankles and 2+ elsewhere. Her gait is normal. Sensation to vibration is mildly decreased over the toes. On mental status examination, she is awake, alert, and conversant. Her language function is normal. She is oriented to person, place, and time and recalls one out of three objects after 10 minutes. Which of the following findings in this patient warrants further evaluation?

A ) Decreased deep tendon reflexes at the ankles

B ) Decreased sensation to vibration over the toes

C ) High-frequency hearing loss

D ) Memory loss

E ) Tremor of the outstretched hands

5. A 42-year-old woman comes to the physician because of a 3-month history of a recurrent vivid dream that several men are assaulting her and her children. Upon awakening, she is anxious and distressed by the frightening images. She realizes that it is just a dream but is afraid to go back to sleep. She does not know why she is having this particular dream because she has never been the victim of an assault. She drinks two to three cups of coffee each morning. She does not use illicit drugs. Physical examination shows no abnormalities. There is no evidence of depressed mood or hallucinations. Laboratory studies are within normal limits. Which of the following is the most likely diagnosis?

A ) Acute stress disorder

B ) Nightmare disorder

C ) Panic disorder

D ) Sleep apnea

E ) Sleep terror disorder


7. A 24-year-old woman comes to the physician because of constant, severe pain in her neck, shoulders, and back for 3 months. She has been unable to enjoy her usual activities because of the pain. Use of over-the-counter ibuprofen and aspirin has not relieved her symptoms. She has a history of irritable bowel syndrome. Examination shows multiple tender spots over the neck, shoulders, and lumbar spine. Range of motion of all joints is full. There is no evidence of synovitis. Fluorescent serum antinuclear antibody and rheumatoid factor assays are negative. Which of the following is the most likely diagnosis?

A ) Ankylosing spondylitis

B ) Fibromyalgia

C ) Polymyalgia rheumatica

D ) Polymyositis

E ) Seronegative rheumatoid arthritis


8. A 23-year-old woman has pain, cramping, and swelling of the right calf 3 days after an uncomplicated labor and delivery. The right foot is swollen, and there is marked tenderness with dorsiflexion and palpation of the right calf. Examination shows no other abnormalities. A complete blood count and serum electrolyte levels are within normal limits. Which of the following is the most likely cause of this condition?

A ) Hypercoagulable state of pregnancy

B ) Hyperuricemia

C ) Peripheral artery aneurysm

D ) Platelet embolus

E ) Prolonged pressure on the vena cava during delivery


9. An 8-year-old girl with type 1 diabetes mellitus is brought to the emergency department 10 minutes after being involved in a motor vehicle collision. She was in the back seat of a small automobile that was rear-ended. Initially, she was alert during transport and reported bilateral thigh pain, but then she stopped talking, closed her eyes, and became unresponsive to voice; on arrival, she responds to noxious stimuli with brief grimaces and no withdrawal. Her blood pressure is 40/palpable mm Hg, pulse is 148/min, and respirations are 28/min. Air entry is symmetric. The pupils are equal and react to light. No cardiac murmur is heard. The abdomen is soft. There is swelling of the upper portions of both thighs. Her hematocrit is 37%. Which of the following is the most appropriate next step in management?

A ) Measurement of arterial blood gases

B ) X-ray film of the chest

C ) CT scan of the head

D ) Administration of 50% dextrose in water

E ) Infusion of 0.9% saline


12. A 72-year-old man comes to the physician because of a 2-month history of urination twice nightly and occasional urinary frequency and urgency. He has a 15-year history of type 2 diabetes mellitus now moderately well controlled with glyburide. His father was diagnosed with prostate cancer at the age of 70 years, and his sister died of complications from systemic lupus erythematosus. His blood pressure is 135/86 mm Hg. Cardiopulmonary examination shows no abnormalities. Abdominal examination shows no suprapubic fullness or tenderness. There is mild enlargement of the prostate with no palpable nodules. His postvoid residual volume is 10 mL. Serum studies show a urea nitrogen (BUN) level of 45 mg/dL and creatinine level of 3.8 mg/dL. Urine dipstick shows 3+ protein. Which of the following is most likely to have prevented progression of this patient's renal disease?

A ) Intermittent Foley catheterization

B ) Intravenous mannitol therapy

C ) Oral cyclophosphamide and prednisone therapy

D ) Oral enalapril therapy

E ) Oral finasteride therapy

F ) Oral prednisone therapy only

G ) Oral terazosin therapy


3. A 32-year-old woman at 38 weeks' gestation comes for a routine prenatal visit. During routine screening at 28 weeks' gestation, she tested positive for hepatitis B surface antigen. Her pregnancy has been otherwise uncomplicated. Examination shows a uterus consistent in size with a 38-week gestation. Which of the following measures is most likely to decrease the risk for hepatitis B infection in her newborn?

A ) Recommendation of bottle-feeding rather than breast-feeding

B ) Maternal administration of hepatitis B immune globulin (HBIG) now

C ) Neonatal administration of HBIG after delivery and hepatitis B vaccine at 3 months of age

D ) Neonatal administration of HBIG and hepatitis B vaccine immediately after delivery

E ) Cesarean delivery


14. A 57-year-old man is brought to the emergency department 30 minutes after he was found on the floor of his house; he has left hip pain and shortness of breath. He has renal failure but has missed his last two dialysis treatments. His renal failure was caused by inadvertent ingestion of ethylene glycol. His renal function did not improve, and he is currently on the transplantation list. Medications include amlodipine and doxazosin. On arrival, his temperature is 37.5 C (99.5 F), blood pressure is 150/100 mm Hg, pulse is 95/min and regular, and respirations are 24/min. His breathing is rapid and deep. Crackles are heard in the lung bases. Examination shows a soft abdomen. Bowel sounds are normal. The left lower extremity is externally rotated. Laboratory studies show:

Serum
Na+ 135 mEq/L
Cl 102 mEq/L
K+ 7.1 mEq/L
HCO3 12 mEq/L

Arterial blood gas analysis on 4 L/min of oxygen by nasal cannula:

pH 7.22
PCO2 31 mm Hg
PO2 61 mm Hg

An ECG shows peaked T-waves. It will be at least 45 minutes before dialysis can be started. Which of the following is the most appropriate next step in management?

A ) Observation until dialysis is initiated

B ) Intravenous calcium gluconate

C ) Intravenous glucose and insulin

D ) Intravenous 0.9% saline

E ) Intravenous sodium bicarbonate

F ) Rectal sodium polystyrene sulfonate (Kayexalate)


15. A 45-year-old woman comes to the emergency department because of shortness of breath, chest pain, dizziness, and mild numbness and tingling around the lips for 2 hours. She says that she feels like she is going to die. She had three similar episodes last week when she was vacationing at the Grand Canyon; the first episode occurred while crossing a narrow bridge on a donkey. She takes a hypoglycemic drug for type 2 diabetes mellitus, verapamil for hypertension, and sumatriptan as needed for migraine. She is mildly diaphoretic and appears pale. Her blood pressure is 130/90 mm Hg, pulse is 120/min, and respirations are 28/min. Serum glucose level is 120 mg/dL. An ECG shows sinus tachycardia. Sublingual nitroglycerin therapy does not relieve her symptoms and gives her a headache. The most appropriate next step in management is administration of which of the following?

A ) Haloperidol

B ) Lorazepam

C ) Oxygen

D ) Sumatriptan

E ) Verapamil


6. A previously healthy 16-year-old boy is brought to the emergency department 20 minutes after an episode of left arm shaking that lasted approximately 3 minutes. Over the past 2 days, he has had fever and emotional lability. On arrival, his temperature is 38.9 C (102 F). He is somnolent and disoriented to person, place, and time. He responds poorly to pain. Neurologic examination shows no other abnormalities. Laboratory studies show:

Hematocrit 34%
Leukocyte count 6000/mm3
Segmented neutrophils 50%
Lymphocytes 50%
Platelet count 280,000/mm3

Analysis of cerebrospinal fluid shows:
Leukocyte count 120/mm3
Segmented neutrophils 20%
Lymphocytes 80%
Erythrocyte count 300/mm3
Glucose 60 mg/dL
Protein 400 mg/dL

Which of the following is the most likely cause of this patient's neurologic findings?

A ) Bacterial infection

B ) Congenital malformation

C ) Fungal infection

D ) Hemorrhage

E ) Immune-mediated demyelination

F ) Parasitic infection

G ) Viral infection


17. A 67-year-old woman has been intubated for 1 week after undergoing a left lobectomy for lung cancer. She has chronic obstructive pulmonary disease. Her preoperative functional vital capacity was 40% of predicted. She is awake and alert. Her blood pressure is 130/75 mm Hg, and pulse is 72/min. The ventilator settings are a synchronized intermittent mandatory ventilation of 8/min, FIO2 of 40%, and positive-end expiratory pressure of 5 cm H2O. Arterial blood gas analysis shows:

pH 7.42
PCO2 47 mm Hg
PO2 90 mm Hg
O2 saturation 96%

Which of the following is the most appropriate next step in management?

A ) Antibiotic therapy

B ) Bronchodilator therapy

C ) Chest physiotherapy

D ) Decrease inotropes

E ) Diuretic therapy

F ) Fiberoptic bronchoscopy

G ) Heparin therapy

H ) Incentive spirometry

I ) Increase FIO2

J ) Increase inotropes

K ) Increase respiratory rate

L ) Placement of thoracostomy tube

M ) Tracheostomy

N ) Wean from the ventilator


18. A 5-year-old girl with ventricular septal defect is scheduled for tonsillectomy in 2 weeks. She has no known drug allergies. Her temperature is 37 C (98.6 F). Examination shows no abnormalities. Which of the following is the most appropriate prophylaxis prior to tonsillectomy?

A ) Amoxicillin

B ) Ciprofloxacin

C ) Rifampin

D ) Tetracycline

E ) Trimethoprim-sulfamethoxazole

F ) No prophylaxis indicated


9. A 72-year-old man with hypertension has had increasingly severe back pain over the past 2 months. He had a myocardial infarction 4 years ago. He has marked tenderness over T11, T12, L1, and L2. An x-ray film of the lumbosacral spine shows osteoblastic lesions in these vertebrae. Which of the following is the most likely diagnosis?

A ) Abdominal aneurysm

B ) Fibrosarcoma

C ) Metastatic prostate carcinoma

D ) Multiple myeloma

E ) Osteosarcoma


22. A 19-year-old man comes to the physician because of frequent nosebleeds over the past 3 weeks. He has bipolar disorder currently well controlled with lithium carbonate, bupropion, and valproic acid. Physical examination shows no abnormalities except for dried blood in the nares. Mental status examination shows an anxious mood and slight motor restlessness. Serum studies show a lithium carbonate level of 1.3 mEq/L (therapeutic range=0.61.2), and valproic acid level of 77 g/mL (therapeutic range=40100). Which of the following is the most appropriate next step in management?

A ) Measurement of serum aspartate aminotransferase (AST, GOT) activity

B ) Measurement of serum bupropion level

C ) Platelet count

D ) Discontinuation of lithium carbonate therapy

E ) Discontinuation of valproic acid therap


23. After an uncomplicated laparoscopic cholecystectomy, a 62-year-old man has not had any urine output since the Foley catheter was removed 12 hours ago. During the hour before the operation, the 40 minutes of operating room time, and the 2 hours in the recovery room, his fluid input was 2.5 L and urine output was 1 L. Since that time, he has been receiving intravenous 5% dextrose in water with 0.45% saline and morphine. He is awake and alert and has a moderate amount of abdominal pain. Preoperative serum studies showed:

Na+ 137 mEq/L
K+ 4.2 mEq/L
Urea nitrogen (BUN) 18 mg/dL
Creatinine 1.2 mg/dL

One hour after receiving an intravenous bolus of 0.9% saline, the patient does not produce any urine. Which of the following is the most appropriate next step in management?

A ) Increase in the dose of morphine

B ) Intravenous administration of an additional bolus of 0.9% saline

C ) Intravenous administration of doxazosin

D ) Intravenous administration of furosemide

E ) Reinsertion of a Foley catheter


5. A 10-year-old girl is brought to the emergency department because of diffuse, aching abdominal pain, nausea, and recurrent vomiting over the past 5 hours. She has an 8-year history of type 1 diabetes mellitus treated with 20 U of NPH and 6 U of regular insulin in the morning and 14 U of NPH and 5 U of regular insulin in the evening. She appears lethargic but is easily arousable. There is an obvious odor of ketones on her breath. Her blood pressure is 100/70 mm Hg, pulse is 95/min, and respirations are 20/min and deep. Serum studies show:

Na+ 142 mEq/L
K+ 5.3 mEq/L
HCO3 6 mEq/L
Glucose 710 mg/dL

Which of the following laboratory findings is most likely to be increased?

A ) Arterial pH

B ) Serum C-peptide level

C ) Serum magnesium level

D ) Serum osmolality

E ) Serum phosphorus level


26. A 72-year-old man comes for a routine follow-up examination. He has chronic obstructive pulmonary disease treated with -adrenergic agonists and ipratropium by metered-dose inhaler and mild arterial insufficiency of the lower extremities treated with aspirin. His blood pressure is 160/60 mm Hg, pulse is 70/min, and respirations are 12/min. Funduscopic examination shows arteriovenous nicking. Pedal pulses are decreased bilaterally. Which of the following antihypertensive drugs is most likely to cause adverse effects in this patient?

A ) 2-Adrenergic agonist

B ) -Adrenergic blocking agent

C ) -Adrenergic blocking agent

D ) Angiotensin-converting enzyme (ACE) inhibitor

E ) Calcium-channel blocking agent

F ) Loop diuretic

G ) Thiazide diuretic

H ) Vasodilator


27. A 42-year-old woman comes to the physician for an annual pelvic examination and Pap smear. Over the past year, she has had increasing fatigue and difficulty sleeping. She has two children who both attend college. She is currently looking for part-time work outside the home. Her husband has been busy in a new start-up business. Examination shows no abnormalities. Laboratory studies show:

Hemoglobin 15 g/dL
Mean corpuscular volume 95 m3
Leukocyte count 6000/mm3 with a normal differential
Serum
Na+ 145 mEq/L
Cl 102 mEq/L
K+ 4.5 mEq/L
HCO3 25 mEq/L
Urea nitrogen (BUN) 18 mg/dL
Creatinine 1.0 mg/dL
Alkaline phosphatase 70 U/L
Aspartate aminotransferase
(AST, GOT) 22 U/L
Alanine aminotransferase
(ALT, GPT) 19 U/L
-Glutamyltransferase
(GGT) 83 U/L
(N=550 U/L)

Which of the following is the most likely explanation for this patient's laboratory abnormalities?

A ) Acetaminophen

B ) Alcohol

C ) Diphenhydramine

D ) Estrogen effect

E ) Ibuprofen


30. A 17-year-old boy is brought to the emergency department by his parents because of bizarre behavior for 6 hours. Last night he was out with friends, and since returning, he has been confused and has "trashed" his room. His blood pressure is 165/95 mm Hg. He is hypervigilant, has little spontaneous speech, and is disoriented to place and time. He appears catatonic but abruptly becomes assaultive two times and needs to be restrained. Which of the following is the most likely substance taken?

A ) Cocaine

B ) Ecstasy

C ) LSD

D ) Methaqualone

E ) PCP


9. An asymptomatic 32-year-old man comes for a routine health maintenance examination. He has a 10-year history of frequent sinus and pulmonary infections. He had an anaphylactic reaction to a blood transfusion following a motor vehicle collision 3 years ago. His temperature is 37 C (98.6 F). Examination shows mild erythema in the posterior pharynx. The lungs are clear to auscultation. A complete blood count and serum protein electrophoresis are within normal limits. Which of the following is the most likely cause of the frequent infections?

A ) Colonization with Streptococcus pneumoniae

B ) Common variable immunodeficiency

C ) HIV infection

D ) Selective IgA deficiency

E ) X-linked agammaglobulinemia


31. A 37-year-old woman comes to the physician because of a 1-day history of throbbing facial pain. She describes the pain as 7 out of 10 in intensity. Over the past 9 days, she has had nasal congestion, purulent nasal discharge, sore throat, and a nonproductive cough. She does not smoke. Her husband and children have had no recent illness. Her temperature is 38.5 C (101.3 F). Examination shows congested nasal mucosa and purulent discharge on the left. There is tenderness to palpation over the left cheek and no transillumination over the left maxillary sinus. The tympanic membranes are normal, and there is no erythema of the throat. Examination shows no cervical adenopathy. The lungs are clear to auscultation. Which of the following is the most likely causal organism?

A ) Haemophilus influenzae type b

B ) Moraxella catarrhalis

C ) Staphylococcus aureus

D ) Streptococcus pneumoniae

E ) Streptococcus pyogenes (group A)


For each patient with loss of consciousness, select the most likely diagnosis.

A ) Aortic stenosis

B ) Carotid sinus hypersensitivity

C ) Conversion reaction

D ) Hypertrophic obstructive cardiomyopathy

E ) Hypoglycemia

F ) Mitral valve prolapse

G ) Orthostatic hypotension

H ) Pulmonary embolus

I ) Seizure

J ) Vasovagal syncope

K ) Vertebrobasilar insufficiency

36. A 62-year-old woman is brought to the emergency department 1 hour after a 1-minute episode of loss of consciousness; her symptoms began when she stood up after she passed a dark, watery stool. She has had diarrhea and dark stools for 2 days. She has been receiving warfarin therapy for deep venous thrombosis for 2 weeks. On arrival, her blood pressure is 82/60 mm Hg, and pulse is 150/min and regular. She is unable to stand. The lungs are clear to auscultation. A grade 2/6 systolic murmur is heard at the second right intercostal space with no radiation. Examination shows a soft, nontender abdomen. There is 1+ edema of the right lower extremity with no tenderness. Test of the stool for occult blood is positive.


37. A 64-year-old woman has moderately severe postoperative pain 1 day after a total abdominal hysterectomy and bilateral salpingo-oophorectomy. Which of the following is the most appropriate analgesic pharmacotherapy?

A ) Oral aspirin-codeine compound

B ) Oral diazepam

C ) Oral ibuprofen

D ) Intermittent intravenous naloxone

E ) Patient-controlled intravenous morphine

F ) Transcutaneous administration of fentanyl


38. A 72-year-old man comes to the physician because of a 6-month history of mild to moderate shortness of breath when climbing stairs. He had a myocardial infarction 2 years ago and has had an ejection fraction of 35% since then. His only medication is a -adrenergic blocking agent. The lungs are clear to auscultation. Cardiac examination shows an S4 gallop. There is no peripheral edema. Laboratory studies are within normal limits. An ECG shows no acute changes. Which of the following is the most appropriate pharmacotherapy?

A ) -Adrenergic blocking agent

B ) Angiotensin-converting enzyme (ACE) inhibitor

C ) Angiotensin2-receptor blocking agent

D ) Nitrates

E ) Thiazide diuretic


39. A previously healthy 24-year-old woman comes to the physician because of a low-grade fever and a nonproductive cough for 7 days. She has been able to continue her daily activities. Her temperature is 37.7 C (99.9 F). A few scattered inspiratory crackles are heard in the thorax. An x-ray film of the chest shows patchy infiltrates in both lungs. Which of the following is the most appropriate initial pharmacotherapy?

A ) Amoxicillin

B ) Cefaclor

C ) Ciprofloxacin

D ) Erythromycin

E ) Trimethoprim-sulfamethoxazole


41. A healthy 55-year-old man comes for an initial health maintenance examination. His last visit to a physician was over 10 years ago. He does not smoke and drinks only on social occasions. Examination shows no abnormalities. Which of the following immunizations should be administered?

A ) Hepatitis A vaccine

B ) Influenza virus vaccine

C ) Measles-mumps-rubella vaccine

D ) Pneumococcal vaccine

E ) Diphtheria-tetanus toxoid


43. A 21-year-old college student comes to the physician because of acne that developed 4 days ago while she was taking her medical college admission test. She is concerned about her appearance and plans to be in a wedding in 3 weeks. She has had similar episodes that have resolved completely without treatment. Examination shows acute acne over the face with a predominance of comedones and pustules. There is no evidence of chronic scarring. Which of the following is the most appropriate initial step in treatment?

A ) Dietary restriction of chocolates and simple sugars

B ) Dietary restriction of milk products

C ) Topical acyclovir

D ) Topical hydrocortisone cream

E ) Topical retinoic acid


44. A healthy 24-year-old woman comes for a routine health maintenance examination. Menses occur at regular 28-day intervals and last 5 to 6 days. Her last menstrual period was 3 weeks ago. She takes no medications. Bimanual examination shows a 5-cm, mildly tender left adnexa. A pregnancy test is negative. Which of the following is the most appropriate next step in management?

A ) Repeat examination in 2 weeks

B ) Measurement of serum CA 125 level

C ) Measurement of serum -fetoprotein level

D ) CT scan of the pelvis

E ) Diagnostic laparoscopy


45. A 3-year-old boy is brought to the physician because of a 7-day history of fever and a painful swollen lymph node in his groin. This is his sixth episode of lymph node swelling; the previous episodes resolved after drainage and prolonged antibiotic therapy. He also had pneumonia at the age of 12 months that required chest tube placement for drainage. A maternal uncle died during childhood of recurrent infections. The patient is at the 5th percentile for height and weight. His temperature is 38.5 C (101.3 F). Examination shows a warm, tender, erythematous lymph node in the right inguinal area. There are several healed incisions over the inguinal area and neck from old drainage sites. Laboratory studies show:

Hematocrit 35%
Leukocyte count 17,000/mm3
Segmented neutrophils 65%
Bands 10%
Lymphocytes 25%
Platelet count 350,000/mm3

A Gram's stain of the lymph node aspirate shows numerous segmented neutrophils filled with bacteria; cultures grow Staphylococcus aureus. Which of the following is the most likely mechanism for these findings?

A ) Adenosine deaminase deficiency

B ) Consumption of complement

C ) Defective opsonization

D ) Destruction of CD4+ T lymphocytes

E ) Developmental arrest of maturation of B lymphocytes

F ) Dysmorphogenesis of the third and fourth pharyngeal pouches

G ) Impaired chemotaxis

H ) Impaired phagocytic oxidative metabolism


2. An 18-year-old man comes to the physician for an initial examination because of a 3-year history of fatigue and migrating joint pain. He has brought a large folder containing information about previous medical consultations, laboratory tests, and x-ray films. He takes no medications. He weighs 50 kg (110 lb) and is 173 cm (68 in) tall. Physical examination shows no other abnormalities. On mental status examination, he is preoccupied with his symptoms. When asked about his mood, he states that the future appears bleak, and that he is too tired to think about it. Which of the following is the most appropriate next step in management?

A ) Ask about further symptoms of obsessions and compulsions

B ) Ask about sexual history including sexual orientation and practices

C ) Ask about suicidal feelings

D ) Ask about travel history over the past 6 months

E ) Obtain a detailed exercise history

F ) Measurement of serum Lyme (Borrelia burgdorferi) antibody level

G ) Urine toxicology screening


4. A 13-year-old girl is brought for a well-child examination. Menses have occurred every other month since menarche 10 months ago. Her last menstrual period was 1 week ago. She is not sexually active. Sexual development is Tanner stage 3. Examination shows no abnormalities. Which of the following is the most appropriate next step in management?

A ) Discussion of pregnancy prevention

B ) Measurement of serum luteinizing and follicle-stimulating hormone levels

C ) Urine -hCG test

D ) Pelvic examination

E ) Estrogen therapy

F ) Diagnostic laparoscopy


3. Three days after being hospitalized for treatment of a hip fracture sustained in a fall, a 62-year-old woman becomes acutely short of breath and coughs up a small amount of blood-tinged sputum. She appears anxious. Her blood pressure is 110/70 mm Hg, pulse is 110/min, and respirations are 24/min. Examination shows no other abnormalities. Arterial blood gas analysis on 40% oxygen by face mask shows:

pH 7.40
PCO2 38 mm Hg
PO2 70 mm Hg

Ventilation-perfusion lung scans show multiple segmental areas of mismatch on the right. Which of the following is the most appropriate next step in management?

A ) Pulmonary angiography

B ) Dopamine therapy

C ) Heparin therapy

D ) Urokinase therapy

E ) Intubation


14. A 16-year-old boy with neurofibromatosis is brought for a follow-up examination. His uncle also has neurofibromatosis. He has a 1-year history of headaches during which his parents say he appears pale. Six months ago, he underwent operative treatment for an optic nerve glioma. His blood pressure is 164/105 mm Hg, pulse is 102/min, and respirations are 14/min. The thyroid glands are not enlarged. No murmurs are heard, and radial pulses are equal. Abdominal examination shows no abnormalities. Which of the following is the most likely cause of this patient's high blood pressure?

A ) Catecholamine-producing tumor

B ) Carcinoma of the thyroid gland

C ) Essential hypertension

D ) Overproduction of aldosterone from an adrenal adenoma

E ) Postsubclavian coarctation of the aorta


20. A 26-year-old woman is brought to the emergency department because of marked confusion for 2 hours; she also has had a flu-like illness for 3 days. Over the past 6 weeks, she has had increased fatigue, weakness, and nausea. She recently started thyroid hormone replacement therapy for autoimmune thyroiditis; 1 week ago, her serum thyroid-stimulating hormone level was 3 U/mL. Her temperature is 38 C (100.4 F), blood pressure is 80/40 mm Hg, and pulse is 140/min. She appears confused and lethargic. Examination shows cool, mottled skin. There is generalized hyperpigmentation, especially involving the palmar creases. The lungs are clear to auscultation. Abdominal examination shows diffuse mild tenderness and no rebound. Laboratory studies show:

Hemoglobin 10 g/dL
Leukocyte count 9000/mm3
Segmented neutrophils 55%
Eosinophils 20%
Lymphocytes 25%
Serum
Na+ 124 mEq/L
Cl 92 mEq/L
K+ 6.4 mEq/L
HCO3 16 mEq/L

An x-ray film of the chest and urinalysis show normal findings. An ECG shows sinus tachycardia with peaked T waves. Which of the following is most likely to confirm the primary cause of this patient's condition?

A ) Measurement of pulmonary artery pressure

B ) Measurement of right atrial pressure

C ) Measurement of serum antithyroglobulin antibody level

D ) Measurement of serum lactate dehydrogenase activity

E ) Measurement of serum thyroid-stimulating hormone level

F ) ACTH stimulation test

G ) Dexamethasone suppression test

H ) Blood cultures

I ) Echocardiography


22. A 32-year-old man with alcoholism is brought to the emergency department by friends because he has been unable to stand without support and has had "funny eye movements"; they report that he has been drinking approximately 18 beers daily over the past month and has been increasingly confused over the past 5 days. He is awake and confused but is noncombative. His speech is slurred, and his breath smells of alcohol. His temperature is 37.2 C (99 F), blood pressure is 180/60 mm Hg, pulse is 110/min, and respirations are 18/min. Physical examination shows sixth cranial nerve palsy, horizontal diplopia, strabismus, and an asymmetric horizontal-gaze evoked nystagmus. Neurologic examination shows no focal weakness or numbness. When helped up and told to walk, he has a broad-based, uncertain gait. When asked how he arrived at the emergency department, he relates that "I drove to this place to visit some friends." The most likely cause of these findings is a deficiency of which of the following?

A ) Folic acid

B ) Magnesium

C ) Vitamin B1 (thiamine)

D ) Vitamin B12 (cyanocobalamin)

E ) Zinc


23. A 19-year-old primigravid woman at 34 weeks' gestation comes to the physician for a routine prenatal visit. Her pregnancy has been uncomplicated. She has no history of serious illness. She takes no medications and has no known allergies. Examination shows a uterus consistent in size with a 34-week gestation. A routine clean-catch urine culture grows greater than 100,000 colonies/mL of Escherichia coli. Which of the following is the most appropriate pharmacotherapy?

A ) Ampicillin

B ) Ciprofloxacin

C ) Clindamycin

D ) Doxycycline

E ) Trimethoprim-sulfamethoxazole


27. A 77-year-old woman comes to the physician because of low back pain for 3 months. She has hypertension controlled with a calcium-channel blocking agent and type 2 diabetes mellitus controlled with diet. Her vital signs are within normal limits. Examination shows no spinal or costovertebral angle tenderness; straight-leg raising produces pain in the low back at the L24 range. Knee jerk and ankle reflexes are 2+ bilaterally. Babinski's sign is absent bilaterally. Urinalysis shows 510 epithelial cells/hpf, 25 leukocytes/hpf, and few bacteria. Which of the following is the most appropriate pharmacotherapy?

A ) Acetaminophen

B ) Gold

C ) Methotrexate

D ) Prednisone

E ) Probenecid
.

26. A 14-month-old girl is brought to the physician because of a 14-hour history of irritability and episodes of drawing her knees toward her chest. During this period, she has vomited nonbilious fluid twice and had a bowel movement containing a small amount of blood. She had an upper respiratory tract infection 2 weeks ago. She is listless except for intermittent episodes of discomfort. Her temperature is 38 C (100.4 F). Abdominal examination shows right-sided tenderness without guarding or rebound; bowel sounds are present. Rectal examination shows bright red blood and mucus. An x-ray film of the abdomen shows no abnormalities. Which of the following is the most appropriate next step in management?

A ) X-ray film of the upper gastrointestinal tract with contrast

B ) Water-soluble contrast enema

C ) Corticosteroid enemas

D ) Admission to the hospital for total parenteral nutrition

E ) Immediate laparotomy


28. A 72-year-old man comes to the emergency department after a 5-minute episode of blindness in the right eye. Over the past month, he has had headache and pain in the jaw with chewing. His temperature is 38.1 C (100.6 F). Examination shows tender, nodular temporal arteries with decreased pulses. His erythrocyte sedimentation rate is 92 mm/h. Which of the following is the most appropriate immediate step in management?

A ) Carotid ultrasonography

B ) Aspirin therapy

C ) Cefotaxime therapy

D ) Corticosteroid therapy

E ) Temporal artery biopsy


32. A 37-year-old woman comes to the physician because of an itchy rash over her trunk for 2 weeks. She has not had fever, chills, shortness of breath, chest pain, or gastrointestinal symptoms. She has a history of recurrent urinary tract infections and has been taking trimethoprim-sulfamethoxazole prophylaxis for the past year. She is in mild distress. Her temperature is 37.5 C (99.5 F), blood pressure is 96/62 mm Hg, pulse is 78/min, and respirations are 14/min. Examination shows a maculopapular erythematous rash over the trunk. Laboratory studies show:

Leukocyte count 10,500/mm3
Segmented neutrophils 72%
Bands 1%
Eosinophils 15%
Lymphocytes 4%
Monocytes 8%
Serum
Urea nitrogen (BUN) 12 mg/dL
Creatinine 0.9 mg/dL
Urine
WBC 2/hpf
RBC 2/hpf

Which of the following is the most likely cause of these findings?

A ) Eczema

B ) Medication adverse effect

C ) Staphylococcal skin infection

D ) Streptococcal skin infection

E ) Urinary tract infection


35. A 67-year-old woman comes for a routine health maintenance examination. She drinks 1 ounce of alcohol daily. Her blood pressure is 138/62 mm Hg, pulse is 76/min and regular, and respirations are 14/min. The lungs are clear to auscultation. The remainder of the examination shows no abnormalities. Laboratory studies show:

Hemoglobin 12.8 g/dL
Serum
Ca2+ 11.9 mg/dL
Creatinine 0.8 mg/dL
Phosphorus 2.8 mg/dL
Total protein 6.5 g/dL
Albumin 4.2 g/dL
Ionized calcium 5.8 mg/dL (N=4.55.1)

Which of the following is the most appropriate next step in management?

A ) Measurement of serum alkaline phosphatase activity

B ) Measurement of serum parathyroid hormone level

C ) Measurement of serum vitamin D level

D ) Serum and urine protein electrophoresis

E ) X-ray film of the chest

F ) Skeletal survey

G ) Bone scan

41. A 27-year-old man comes to the physician because of a 1-week history of shortness of breath with exertion, paroxysmal nocturnal dyspnea, and swelling of his feet. He has not had chest pain or palpitations. He has been healthy except for a "bad cold" 1 month ago that resolved spontaneously after 10 days. His temperature is 37 C (98.6 F), blood pressure is 90/60 mm Hg, pulse is 120/min, and respirations are 24/min. Examination shows jugular venous distention to 8 cm. Bilateral basilar crackles are heard. Cardiac examination shows a diffuse, laterally displaced point of maximal impulse. There is a normal S1 and S2 and an S3. Examination shows 2+ pretibial edema bilaterally. An ECG shows no abnormalities. Echocardiography is most likely to show which of the following?

A ) Asymmetric septal hypertrophy

B ) Bicuspid aortic valve with stenosis

C ) Diffuse hypokinesia and dilation of the ventricles

D ) Dyskinesia of the left ventricular apex

E ) Mitral valve prolapse


42. A 24-year-old man is brought to the emergency department by police 1 hour after his ex-wife found him stumbling around in the yard. His blood pressure is 100/70 mm Hg, pulse is 90/min, and respirations are 16/min. The pupils are equal and reactive to light; the sclerae are injected. During the examination, he laughs without obvious reason, makes religious statements, and asks if there is anything to eat or drink. Mental status examination shows a broad range of affect; there is no evidence of thought disorder except for mild paranoia. Which of the following is the most appropriate next step in management?

A ) Observation in the emergency department

B ) Intramuscular administration of naloxone

C ) Intravenous administration of 50% dextrose

D ) Intravenous administration of lorazepam

E ) Oral administration of chlorpromazine


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